NO PERMIT NUMBER APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO
BUILDING G-F.ECHA ICA PERMIT NO.
APPLICATION/PERMIT PING PROG-b1ECHANICAI.
ItUII,DINC DIVISION � RUILDINC,PROJECTIDENTIFICATION
BUILDING ADDRESS: Drill
SAN]EARY NO. APPLICATION SUBMITTAL DATE
1,582 a n l
OWNERS NAME: p� IC fsIIVNH: Du"7444�j3 CONTRACTOR'SCNAMI3: LIC NO: N/C CON*UR0LN
To p
RCHITEC'DENGINEER: 1✓ LIC N•O: ADDRESS: ❑ '
N A
CONTACT. PHONE: 404MERIOR
UILDING PERMITINFO
❑ Consultant Fees Paid by Applicant(Initial) ELECT PLUMB MECH
LICI.NSF.D CONT'RACTOR'S DFCLARATION QTY. ELECTRIC PERMIT
I hereby ofGmt that I mai licensed under provisions of Chapter 9(commencing - "' JOB DESCRIPTION
^ WoZ wilb Scction]Wo)nl'Divisintq of the Rosiness and Pml'cssinnsCNe,and mylimnxe is ALm00 I'13RMIT ISSUANCE FIy in full force and etfen. ❑KI'I CI IFN RE MODEL
UU License Class Lie p APPLIANCES-RISIDENTIAL ❑PLUMBING RE-PIPE
Z W Data Contractor
6 T ❑STRUCTURAL
, ARCHITECTS DECLARATION PANELSZ 0 Z I understand my plans shall be used as public forums A10D110CATION
0Z�0 UP TO 200 AMPS (3 CH HANEY REPAIR
F.N..~.W Licensed Professional 201401MAMPS IMPROVEMENT [3 SWIMMING POOLS
qq OWNHR-BUILDER DECLARATION OVER I"AMPS ❑BATH REMODEUREPAIR ❑DIiMOLITION
m�m� 1 hereby efrom that I ata exempt from the Commanns License Law for the
Q.2 In rat IDanO)iM W
�p�V ®OTlfl?R �_
following reason.(Section]onstr t.alter. andProfessions
improve,
de in demolish,
Coda:Any oily or county SIGNS ELECTRICAL
a u which,refaindsiwa a permit r coosoua,aper improve,demm 1 file
repair any ewcmre sheG^I � mod ns f He
,F„�0� pri.rmiu ixwance..l.an rayuires the applicant for each permit In lite signed imtemenl SPECIAL CIRCUIT'/MISC. - -
FvW1} him he is licensed pursuanuo the provisionsofthe Contractors license Law(Chapter 9
MCOO (commencing with Section 7")of Division 3 ofthe Business and Professions Coca)or 'TEMP.METERORVOL.F:INS'K COMMERCIAL
IUa o� that he is exempt therefrom and the basis for Ne alleged exemption.Any violation of ❑NEN'BLDG/ADDITION ❑DEMOLITION
�m
Section 70315 by anyapplicmn faro permit subjects the aPPlic.nt m a civil penalty of POWER DEVICES I []TENANT ❑FOOD SERVICE
not more than five hommeddollar,W00). I IMPROVEMENT
M rwLmowoerofdre Pimlico, employees with wages as their sole compensation, SWIMMING POOL HLECT C
2 will do the work,and dwormealre is not intended orolfered for sale(Sec. Business �• ❑OTHEN
L m and Professions Codd:The Conm®lots License Law does not apply to an owner of Ulll'LF:TS;SWITCItliS-FIXTURES
prnl<ny who builds or ingmovcs thcm.n,and who dims inch wink Itbnsalf ar mon gh
fix awn employees,provided that such improvemems am not intended or offered for NEW RESIDENTIAL CLECIN SQ f
sale.ILhowevm the building or improvement is sold within one year ofcomp—......hc SQ.I"fJLUUR AREA SISQIT.
.
posmer-builder will have the lumen of proving that heard not build or improve for pur-
e of cele.). fill
I,as owner of the property,am exclusively contracting with licensed annunciators to
ansouct the projxs(Sec.RWI,Business and professions Code:)The Caricatures Li-
cense law does not apply man owner of property who builds or Improves thereon,and QTY, PLUMBING PERMIT FEE
who contracts for such projects with a contrecmds)licensed pursuam to the Comment's
License law. PERMIT'ISSUANCE PAID
I am exempt under See. _ .B&P C for this reason
' ALTER-pRA1N&VHN'I'-WATER(f3A) AfAATION
Owner Date p��Y 1 6 A[I1a)
WORKER'S COMPENSATION DECLAMATION BACK FLOW PR'JT'13CT.DEVICE PEI)
GFJ 1 hereby from under pcwhy of pepury one of the following declsos mm:
I have and will maintain a Certificate of Conant to self-insum for Wort Compen- DRAINS-FLOOR,ROOR AREA,GOND. /v 51pg1Eg CONSTRUCTION
cation,as provided for by Section 37W of the Labor Code,for the perfmrs
ooe of He — ,Urct MCI CI
work fair which this permit is issued. FIXTURES-PER TRAP
1 have and will maintain Workers Compensation Insurance,as required by Section
311X1 of the Labor Code,far the prrisn
lnance of the work far which this permit is issued. GAS-F.A.SYSTEM-1 INC.40UTLETS OCC.GROUP AI'N
My Worker's Compensation Insurance comer and Policy number arc:
Carrier Puliey No.: GAS-EA.SYSTEM.OVER 4(EA)
CERTIVICA'I'B OF EXEMPTION FROM WORKERS' GREASEINDUSTRI.WAS TE INTI3BCEPTOR
COMPENSATION INSURANCE _ BUILDING DIVISIO-f3CS�
(Otis section oenl not he<nmplmed stubs pemrit is fnnmc hundreddollnrs($I W I
.r las.) GREASETRAP PfANC11
Icenify that in the performance of the work for which this pemtit is isrved.I shall SEWER-SANITARY-STORM FA.2W FE
ENERGY F[E
am employ anperson peon in any manner sat as to become attract to the Workers'Camper.
J
Zsmina Laws of California.Data WATER HEATER WNP.Nf/ELECIR
Q Applicant s - GRADING P
Ll
— NOI ICE TO APPLICANT:II:after..king this Ccnificam of EsOntimm,you should WATER SYSTlzmffR13ATINC,
F' [^ become s0jaci m the Worker's Comprootion provisions of Ilia Labor Code,you must SOILS Ii31i
Gall Iti fimhwith comply wlthsnch provisions or this Farrah shall lw Metned revoked. WATER SERVICELU
Q
d
CONS'TRUCIIUN LENDING AGENCY NEWRESIDENTIALPLMB.' SQ.Fr. PAID
U 0 (hereby affirm Hat is a concoction lending agency for the performance of VI DImVI ° t
w - the work for which this permit is issued(Sm.300,CiN,C.) TOTAL:
0U Lenders No.
Landee,Address TOTAL:
W 1 mrody that 1 have trod this application and sntu that the alaoc information is BUILDING ITH
On cnaccl.lagree income],with all city wad county mdurnces and xaid laws relmin, a QTY. MECHANICAL PERMIT FEE
U .I hulldingeonswe0on.and hereby amhocim repraemmtivesofdiNcitym entefupan theSEISMIC tTl3 D
donswo catloned pm,oy fur inspect,Purpnsa'. PERMIT'ISSUANCI3� 3940
(We)agree m save,indemnify and keep harmless the City of Cupertino against ELECTRIC 1:17H
lrhaities,adgotenu,costsand expenses which may inany w.y.carre.mosteud City ALTER OR ADD TO MF.CH
in consequence of the granting of this permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO I0,000CFM) MECHANICAL.FEE
SOURCE REGULATIONS.
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
Signature mApp[icanVC.nweer Date EXHAUST HOOD(WMUCf) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building rcalpirm,lore or handle hazardous material UEAT'I INC,UNIT(TO BROOM BTU)
to,defined by the Cupanlnu Municipal Code,Chapter 9,12,and the Health and Safety
Cala,Seen..25532m)Y 1[EATING UNIT(OVER HNIpW BTU)
Yes F1 Na� VENTILATION PAN[SINGLE RESII]) PAID pate Receipt X
Will the applicant ar future building cataract use equipment or devices which
emit hazardous air conta.iwms as defined by the Bay Area Air Quality Marmgement BOILER-COMP DUIP OR IW,IXXT BTU) TOTAL: y
DisrW,
et! BOILER-COMP(OVIX I000 BTU) �+
❑Yes ❑No
I have read the hazardous mmeriols mgnirements under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
but a Haerh&Safe,Code,Sections 25505,25533 and 25534.1 understand that If the NEW RESIDENTIAL MSCI I. SQ.Fr.
loilding dans not currently have a tenant;that it is my responsibility m notify he occurymt
of the requirements which must he nun prior to issuance of a Certificate of Occupancy.
Owner m authorized.,car Date TOTAL[ ISSUED BY:
OFFICE